ARTICLES
A Randomized Placebo-Controlled Trial of a School-Based Depression Prevention Program

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ABSTRACT

Objective

To conduct a placebo-controlled study of the effectiveness of a universal school-based depression prevention program.

Method

Three hundred ninety-two students age 13 to 15 from two schools were randomized to intervention (RAP-Kiwi) and placebo programs run by teachers. RAP-Kiwi was an 11-session manual-based program derived from cognitive-behavioral therapy. The placebo was similar but with cognitive components removed. Outcomes were self-rated depression scales, the Reynolds Adolescent Depression Scale (RADS), and the Beck Depression Inventory II (BDI-II). Follow-up was to 18 months. Analysis was done on an intent-to-treat basis.

Results

Immediately after the intervention, depression scores were reduced significantly more by RAP-Kiwi than by placebo, with a mean difference in change from baseline between groups of 1.5 on BDI-II (CI > 0.38, p = .01) and 2.24 on RADS (CI > 0.22, p = .04). Categorical analysis confirmed significant clinical benefit with an absolute risk reduction of 3% (95% CI, 1–11%, McNemar χ2, p = .03), with the “number needed to treat” for short-term benefit of 33. Group differences in depression scores averaged across time to 18 months were significant on RADS but not on BDI-II. Retention rates were 91% at 6 months and 72% at 18 months.

Conclusions

The RAP-Kiwi program is a potentially effective public health measure. Confirmation of effectiveness measuring episodes of depressive illness and broader measures of adjustment is warranted.

Section snippets

DEPRESSION PREVENTION PROGRAMS

Depressive disorder usually starts in adolescence, with a marked increase in period prevalence estimates from middle to late adolescence (Fergusson and Horwood, 2001; Hankin et al., 1998), making this a good time to intervene to prevent onset. Depression prevention programs may include programs that are targeted (i.e., delivered to those at risk of disorder) or universal (i.e., delivered to the whole population). Targeted prevention programs can be divided into selective approaches aimed at

PLACEBO STUDIES

A major weakness of studies of depression prevention to date has been the lack of active comparison groups. The strength of the placebo effect in the reduction of depressive symptoms is well established (Shapiro and Shapiro, 1997). Only two reported randomized controlled trials have used an active comparison. Neither showed efficacy, but the condition described as placebo in one included active therapeutic elements (Shatte, 1997) and the other did not have power to detect a difference (Pattison

Study Participants

Participants were recruited from two different years in two schools in Auckland, New Zealand. One of these schools, school A, was from a lower socioeconomic urban area; the other, school B, was from a middle-class rural district. The schools were selected on the basis of their ethnic mix, almost purely Maori and Pakeha, and the numbers on their rolls. Most other schools in Auckland have a substantial number of students of Pacific Island or Asian ethnicity. All students in year 10 at school A

RESULTS

Of 540 students, a total of 392 (72.6%) could speak English, agreed to participate, and returned written consent forms; of these, 189/318 (59%) were from school A and 203/222 (91%) were from school B. The main reason for nonparticipation was failure to return a signed consent form from parents. We had 7 active refusals from school A and 12 from school B. The 392 students were randomized to intervention (207) and control (185). Eleven students in each group were referred to the school guidance

Summary of Findings

In this, the first substantial study to compare a depression prevention program with a placebo, we have shown a significant effect for RAP-Kiwi immediately after intervention on both measures of depression. Following RAP-Kiwi the scores remained lower at all time points at follow-up to 18 months on the RADS but not on the BDI-II when averaged across time (the area under the curve calculations). This is suggestive of a persisting effect that is small but statistically significant. We consider

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  • Cited by (0)

    The research was supported by the Health Research Council , Grant No. 99/039 . Our thanks to the students and teachers who participated in the study; Dr. Shochet for generous support; Ms. Muller, Mr. Wharemate, Mr. Dutt, Dr. Crengle, Mr. Stewart, Mr. Leo, and Dr. Foliaki for advice over cross-cultural issues; Ms. Wills, project coordinator; Dr. Plunket, who designed the graphics; Prof. Merry and Dr. Frampton for advice about design and analysis.

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